DA Form 5179 "Medical Record - Preoperative/Postoperative Nursing Document"

What Is DA Form 5179?

This is a military form that was released by the U.S. Department of the Army (DA) on June 1, 1991. The form, often mistakenly referred to as the DD Form 5179, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 2-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 5179 down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 5179 "Medical Record - Preoperative/Postoperative Nursing Document"

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PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
For use of this form, see AR 40-66; the proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
1.
AGE:
HEIGHT:
[
]
NO
[
]
YES (type):
3. PREVIOUS SURGERY
WEIGHT:
4. PROPOSED SURGICAL PROCEDURE:
5. ADDITIONAL INFORMATION:
6. PATIENT PROBLEMS AND NEEDS
7. PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS
o
Allow pt. to verbalize
A. PSYCHOSOCIAL
o
Pt. verbalizes any specific anxiety.
freely.
o
Explain OR environment
Potential for anxiety
and answer questions
o
Pt. exhibits relaxed body posture.
related to
regarding surgery.
o
Offer comfort measures,
(e.g., warm blanket, touch)
o
Explain all nursing
procedures before they are
done.
Remain with pt. whenever
o
possible.
o
Maintain family interface.
PT. will be able to breathe without
o
B. AERATION
o
Offer to elevate head of
difficulty during immediate intra-
litter or offer pillow.
Potential for
operative phase.
o
Observe pt. while awaiting
respiratory dysfunction due to
surgery for signs of distress
o
Assist anesthesia during
intubation and extubation
PT. will not exhibit signs of impair-
o
o
Utilize pressure preventing
C. INTEGUMENT
ment of skin integrity (e.g., reddened
devices on OR table and
areas.
accessories.
Potential impairment
Check for proper
o
of skin integuity due to
positioning and support to
maintain good body alignment.
o
Pad pressure points.
Place ESU ground pad on
o
non compromised skin surface
area.
o
Keep prep fluids from
pooling.
9. PATIENT'S IDENTIFICATION
(For typed or written entries
give: Name- last, first, middle; grade; date; hospital or medical facility)
Previoius editions are obsolete.
DA FORM 5179, JUN 1991
APD LC v1.03ES
PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
For use of this form, see AR 40-66; the proponent agency is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication):
1.
AGE:
HEIGHT:
[
]
NO
[
]
YES (type):
3. PREVIOUS SURGERY
WEIGHT:
4. PROPOSED SURGICAL PROCEDURE:
5. ADDITIONAL INFORMATION:
6. PATIENT PROBLEMS AND NEEDS
7. PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS
o
Allow pt. to verbalize
A. PSYCHOSOCIAL
o
Pt. verbalizes any specific anxiety.
freely.
o
Explain OR environment
Potential for anxiety
and answer questions
o
Pt. exhibits relaxed body posture.
related to
regarding surgery.
o
Offer comfort measures,
(e.g., warm blanket, touch)
o
Explain all nursing
procedures before they are
done.
Remain with pt. whenever
o
possible.
o
Maintain family interface.
PT. will be able to breathe without
o
B. AERATION
o
Offer to elevate head of
difficulty during immediate intra-
litter or offer pillow.
Potential for
operative phase.
o
Observe pt. while awaiting
respiratory dysfunction due to
surgery for signs of distress
o
Assist anesthesia during
intubation and extubation
PT. will not exhibit signs of impair-
o
o
Utilize pressure preventing
C. INTEGUMENT
ment of skin integrity (e.g., reddened
devices on OR table and
areas.
accessories.
Potential impairment
Check for proper
o
of skin integuity due to
positioning and support to
maintain good body alignment.
o
Pad pressure points.
Place ESU ground pad on
o
non compromised skin surface
area.
o
Keep prep fluids from
pooling.
9. PATIENT'S IDENTIFICATION
(For typed or written entries
give: Name- last, first, middle; grade; date; hospital or medical facility)
Previoius editions are obsolete.
DA FORM 5179, JUN 1991
APD LC v1.03ES
6. PATIENT PROBLEMS AND NEEDS
7. PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS
o
Pt. will exhibit signs of adequate
D. CIRCULATION
o
Check for support stockings or ace
tissue perfusion (e.g., color, warmth,
wraps. If none, check with doctors.
Potential for inade-
Check that safety straps are
o
pedal pulse).
quate tissue perfusion due to
correctly applied.
o
Offer pillow for under knees.
o
Place and take down legs from
stirrups with slow bilateral motion.
Check that rings have been
o
removed.
Pt. will be transferred to OR table
o
o
Have sufficient people
E. NEUROMUSCULAR
available for transfer.
without difficulty.
CONTROL
o
Insure proper body
Pt. will not experience unnecessary
o
E.1.
Potential impairment
alignment.
physical discomfort.
Allow patient to lie in
o
of mobility due to
position of comfort while
waiting for surgery.
o
Offer support (i.e., pillows,
E.2.
Potential discomfort
bathtowels, etc.) for
due to
positioning.
Pt. will be made aware of
o
o
Introduce self. Keep pt.
F. NEUROMUSCULAR
surroundings prior to anesthesia
informed as to where he/she is
CONTROL
induction.
and what is happening.
Disminished visual
F.1.
o
Pt. will be transferred safely to
Inform pt. in which
o
perception due to being
direction to move and assist if
OR
necessary.
table.
Speak clearly and slowly.
o
Pt. will be able to understand
o
Potential for decreased
F.2.
Address pt. from
o
instructions.
communictaion due to
side.
Minimize danger of injury during
o
o
Validate pt.'s
intraop period.
understanding of verbal
Potential injury due to
F.3.
communications.
dentures.
Verify removal of dentures.
o
G. OTHER PATIENT PROBLEMS
OTHER PATIENT GOALS AND EXPECTED
OTHER NURSING INTERVENTIONS.
NEEDS. Or continuation of above
OUTCOMES. Or continuation of above goals
Or continuation of above
problems/needs.
and outcomes.
interventions.
10. OR NURSING INTERVENTIONS COMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED.
DATE
11. POSTOPERATIVE EVALUATION:
12. PREOPERATIVE EVALUATION PREPARED BY
13. PREOPERATIVE EVALUATION PREPARED
(Signature and Title)
BY (Signature and Title)
DATE:
TIME:
DATE:
TIME:
REVERSE OF DA FORM 5179, JUN 1991
APD LC v1.03ES
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